A bullock trampling upon a person's neck can result in laceration wounds, tracheal injury, cervical spine injuries and concussion. We present a case of a farmer, whose neck was stamped upon by a bullock, resulting in right internal carotid watershed infarct due to dissection of right common carotid artery.

A 67-year-old farmer was admitted with history of accidental injury to head and neck by the hoof of a bullock after fall from a bullock-cart. Patient's neck was trampled upon and he became unconscious. He was referred to our centre after first aid.

Patient was unconscious and cyanosed. Emergency tracheostomy was done for stridor due to a large hematoma on right side of the neck compressing the trachea. Patient was transferred to orthopedic care suspecting cervical spine injury. Patient's sensorium improved over three days but he was unable to move the left side of his body. Computed tomography (CT) scan of the brain and cervical spine revealed intra and inter-muscular hematoma on right side of the neck, however, there was no fracture of the cervical spine or calvarium. On transfer to the medicine unit, the patient was conscious, oriented, with left hemiplegia. The left plantar was extensor. Right eye was aphakic with irregular pupil and corneal opacity. Magnetic resonance imaging (MRI) of brain revealed right internal carotid artery watershed infarct with right scalp hematoma [Figure 1]. Magnetic resonance angiography (MRA) of head and neck showed occlusion of the right common carotid artery distal to the origin of the right subclavian artery [Figure 2]. Patient was started on anticoagulation and physiotherapy. Power improved gradually to 3/5 in left limbs. The patient was discharged a month later after tracheostomy tube was removed.

Medieval means of transport like a bullock-cart are still a part of life in rural India. Our patient's neck was trampled upon by a bullock with resultant left hemiplegia due to right common carotid artery dissection (CAD). Blunt injury to the cervical carotid artery may lead to a dissection with resultant occlusion, stenosis, aneurysm, or a combination of all three. [1] CAD is reported following deceleration trauma, sports injuries, violent vomiting, coughing and nose blowing, prolonged telephone calls and roller-coaster rides. Maxillofacial surgery and bronchoscopy are the iatrogenic causes. [2] The diagnosis is suspected by transient unilateral blurring of vision or weakness with Horner's syndrome. [3] Other features include craniocervical pain, cranial nerve palsy and pulsatile tinnitus. Delayed strokes are not unusual.

A combined MRA and MRI of the neck allow both the luminal narrowing and intramural clot to be seen. Doppler scanning can be used for follow-up. "String sign," pseudo-aneurysm, double lumen or intimal flaps have been described on conventional angiography. The mainstay of treatment is anticoagulation with heparin followed by warfarin till the stenosis improves. [4],[5],[6] Surgical or endovascular treatment should be reserved for anticoagulation failure. [7]

A case report of right CAD after being hit by a cow's tail has been described in a farmer's wife, resulting in delayed left hemiplegia. [8] In our patient the possible mechanism for CAD was arterial dissection due to direct hoof injury. However, it is possible that the hematoma itself could have caused compressive occlusion of the common carotid artery eventually followed by dissection at its origin (given the fact that the transfer of patient from his village to our hospital took 8 h)